Nicola Doldi

Pathologic findings in hysteroscopy before in vitro fertilization-embryo transfer (IVF-ET)

Background. The aim of this study was to evaluate hysteroscopy routinely performed prior to in vitro fertilization-embryo transfer (IVF-ET). Methods. We analyzed in a prospective study 300 patients who underwent hysteroscopy before the first IVF-ET cycle. We analyzed then in a retrospective manner 300 patients who did not perform hysteroscopy. Results. One-hundred-and-eighty (60%) hysteroscopies were normal but 120 (40%) revealed an unsuspected intrauterine abnormality. We did not find statistically significant differences between patients with normal or abnormal hysteroscopy in any characteristic. We found a statistically significant difference in pregnancy rate between women who performed hysteroscopy before IVF-ET cycle and in women who did not perform it. Conclusions. Hysteroscopy, as a routine examination, should be performed before the first IVF-ET cycle in all patients.

Vascular endothelial growth factor messenger ribonucleic acid expression in human ovarian and endometrial cancer

Vascular endothelial growth factor (VEGF) is a previously discovered angiogenic factor that seems to influence the neoangiogenesis of neoplastic and non-neoplastic tissues. Substantial experimental evidence links tumor growth and metastasis with blood vessel formation. Tumor angiogenesis can be induced by factors released by the tumor cells themselves. A variety of transformed cell lines expresses the VEGF transcript and secretes an EGF-like protein, suggesting that this angiogenic factor may be one of the mediators of tumor angiogenesis. By Northern blot analysis and in situ hybridization, we investigated the expression of VEGF transcript in human ovarian and endometrial neoplasms. Messenger RNA encoding VEGF was detected in all tissues studied and was more densely expressed in endometrial carcinoma. VEGF expression was also identified in cells obtained from ovarian and endometrial ascitic fluid. VEGF mRNA, detected by in situ hybridization, was identified in the epithelial cells of endometrial adenocarcinoma. This distribution was localized primarily in the apices of the papillae. The prominence of VEGF mRNA levels in human ovarian and endometrial tumors demonstrates that VEGF may be involved in promoting tumor angiogenesis and stroma generation, acting as an endothelial cell mitogen.

Premature ovarian failure: steroid synthesis and autoimmunity.

The androgen biosynthesis and autoimmunity of 25 patients with premature ovarian failure (POF) and 18 control subjects with normal cycles were examined. Serum levels of dehydroepiandrosterone sulfate (DHEAS), 17-hydroxyprogesterone (17-OHP), androstenedione, and testosterone were analyzed in POF patients with or without organ-specific autoimmunity, and the results compared with those of women with normal ovarian function. The comparative analysis of DHEAS, 17-OHP, androstenedione and testosterone showed that POF patients had significantly lower values than normal women (DHEAS, androstenedione and testosterone p < 0.01, 17-OHP p < 0.05). Furthermore, we found one or more organ-specific autoantibodies in 11 patients with POF (44%), while only one woman in the control group showed autoimmunity (antithyroid microsome) (5.5%). Only one patient had both anti-ovarian and anti-adrenal antibodies (4%). The comparison of androgen levels in POF patients with or without autoimmunity revealed a statistically significant reduction of DHEAS levels in POF patients with organ-specific autoimmunity (p < 0.01). These data reveal the reduction in androgen synthesis in POF patients, particularly in those with organ-specific autoimmunity.

Gonadotropin-releasing hormone antagonist and metformin for treatment of polycystic ovary syndrome patients undergoing in vitro fertilization–embryo transfer

Aim. The combination of gonadotropin-releasing hormone (GnRH) antagonist and gonadotropin represents a valid alternative to the classical protocol with GnRH agonist for ovulation induction in patients with polycystic ovary syndrome (PCOS). The use of metformin is of benefit to women with PCOS. The aim of the present study was to compare the stimulation characteristics and in vitro fertilization (IVF)–embryo transfer (ET) outcomes of the standard short GnRH antagonist protocol for ovarian stimulation with or without metformin. Materials and methods. We recruited 40 PCOS patients. The population studied was divided into two groups (A and B). Group A was pretreated for 2 months with metformin 1.5 g/day (Glucophage®; Merck Pharm), and then stimulated with recombinant follicle-stimulating hormone (rFSH) 150 UI/day (Gonal F® 75 UI; Serono). GnRH antagonist, cetrorelix acetate 0.25 mg/day (Cetrotide®; Serono), was started when the leading follicle reached 14 mm diameter on ultrasound scan. Group B was treated only with rFSH 150 UI/day and GnRH antagonist 0.25 mg/day when the leading follicle was ≥14 mm in diameter. Results. In group A we found a statistically significant (p < 0.05) decrease in the number of ampoules of rFSH (A vs. B: 18±6 vs. 24±8) and estradiol levels (A vs. B: 2400±600 vs. 3370±900 pg/ml) (all values mean±standard deviation). Group A had significantly fewer cancelled cycles (A vs. B: 1 vs. 3; p < 0.05). The incidence of ovarian hyperstimulation syndrome was 5% in group A and 15% in group B (p < 0.05). In patients treated with metformin, the total number of follicles on the day of human chorionic gonadotropin treatment (23±1.2 vs. 33±2.6) was decreased with no change in the number of follicles ≥14 mm in diameter (A vs. B: 18±1.2 vs. 19±1.7). However, the mean number of mature oocytes (A vs. B: 8.4±1.5 vs. 5.0±1.5) was increased with metformin treatment (p < 0.05). No difference was found in the number of cleaved embryos (A vs. B: 2.5±0.5 vs. 2.2±0.3). Conclusions. The use of metformin with GnRH antagonist improves the outcome of ovarian stimulation in IVF-ET cycles in PCOS patients.

Hashimoto's disease in a papillary carcinoma of the thyroid originating in a teratoma of the ovary (malignant struma ovarii)

Adenocarcinomas represent a relatively rare complication of a cystic teratoma of the ovary. Those of thyroid origin have been reported in only a few cases. In this paper we report a case of papillary carcinoma of the thyroid arising from a cystic teratoma. The patient had no thyroid symptoms, but because of the presence of antimicrosomal and antithyroglobulin antibodies the diagnosis of Hashimotos disease was made.

In controlled ovarian hyperstimulation, steroid production, oocyte retrieval, and pregnancy rate correlate with gene expression of vascular endothelial growth factor.

Purpose: Whether the gene expression of vascular endothelial growth factor (VEGF) in human granulosa cells is a predictor of fertilization was evaluated in patients participating in an in vitro fertilization program.Methods: Fifty patients with normal ovaries who were participating in an in vitro fertilization program at the University of Milan, San Raffaele Scientific Institute, were included in the study. We correlated E2and P serum levels on the day of oocyte collection, the number of follicles, oocytes collected, and fertilized, and pregnancies with mRNA for VEGF of luteinizing granulosa cells obtained at the time of oocyte retrieval.Results: Comparing E2and P serum levels, the number of follicles, oocytes collected and fertilized, and pregnancies with gene expression for VEGF, we found a positive correlation. E2and P serum levels were higher in patients with increased VEGF (P < 0.01). Furthermore, there were more follicles, oocytes collected and fertilized, and pregnancies in patients with maximum expression of VEGF, and the difference was statistically significant (P < 0.05).Conclusions: Our results suggest that VEGF may be important for vascular development during follicular growth and luteal differentiation, oocyte maturation, and fertilization.

Effects of growth hormone and growth hormone-releasing hormone on steroid synthesis in cultured human luteinizing granulosa cells

To assess the direct effect of growth hormone and growth hormone-releasing hormone on gene expression of steroidogenic enzymes and production of progesterone, 17-hydroxyprogesterone (17-OHP) and estradiol, we cultured luteinizing granulosa cells with or without follicle-stimulating hormone (FSH), growth hormone and growth hormone-releasing hormone at different concentrations. Luteinizing granulosa cells were obtained from women undergoing an in vitro fertilization program in the Department of Obstetrics and Gynecology, S. Raffaele Scientific Institute, Milan, Italy. At a concentration of 1 microgram/ml, FSH significantly increased estradiol production (2.1 +/- 0.7-fold the control value; p < 0.05 vs. control) and progesterone production (3.5 +/- 2.0-fold the control value; p < 0.05 vs. control). Growth hormone was effective on estradiol, progesterone and 17-OHP at 1 microgram/ml, enhancing estradiol production (1.3 +/- 0.2-fold the control value; p < 0.05 vs. control), progesterone production (2.5 +/- 1.0-fold the control value; p < 0.05 vs. control), and 17-OHP (1.4 +/- 0.2-fold the control value; p < 0.05 vs. control). Growth hormone-releasing hormone increased estradiol production (1.5 +/- 1.2-fold the control value) and progesterone production (1.3 +/- 0.8-fold the control value), but not significantly. No effects by growth hormone-releasing hormone were seen on 17-OHP production. FSH, growth hormone and growth hormone-releasing hormone did not increase P450scc and P450 aromatase mRNAs, whereas FSH increased P450c17 mRNA to 150% at 100 ng/ml and 1 microgram/ml, growth hormone increased it to 230% at 100 ng/ml and to 200% at 1 microgram/ml, and growth hormone-releasing hormone increased it to 140% at 100 ng/ml and to 190% of control values at 1 microgram/ml. These results indicate a direct effect of growth hormone on steroidogenesis by increasing P450c17 mRNA accumulation and progesterone, 17-OHP and estradiol production.

Expression of vascular endothelial growth factor in human luteinizing granulosa cells and its correlation with the response to controlled ovarian hyperstimulation

Ovulation induction represents one of the most important steps for the success of assisted reproductive technology (ART) procedures. To better understand the mechanisms that regulate follicle growth, oocyte maturation, and ovarian steroidogenesis, we investigated the correlations between vascular endothelial growth factor (VEGF) gene expression in human luteinizing granulosa cells, steroid production and oocyte retrieval in patients undergoing controlled ovarian hyperstimulation. We evaluated the messenger ribonucleic acid (mRNA) for VEGF in human luteinizing granulosa cells obtained at the time of oocyte retrieval from 24 women participating in an in vitro fertilization program at the Reproductive Endocrinology Center of our Department of Obstetrics and Gynecology. We found a positive linear correlation of VEGF mRNA with estradiol and progesterone serum levels at the day of oocyte retrieval (p < 0.05). Furthermore, VEGF mRNA expression was significantly higher in granulosa cells obtained from patients with an elevated number of oocytes and high fertilization rate (p < 0.05). Our data confirm that VEGF may play an important role in the regulation of vascular development during follicular growth and luteal differentiation.

Treatment versus no treatment of transient hyperprolactinemia in patients undergoing intracytoplasmic sperm injection programs

The aim of our study was to investigate the effect of increased plasma prolactin levels on oocyte and fertilization rate in patients undergoing in vitro fertilization (IVF) intracytoplasmic sperm injection (ICSI) treatment. We identificated 135 patients with transient or borderline hyperprolactinemia, measured in the mid and late follicular phase and in the mid-luteal phase of the cycle before ovarian stimulation. The patients were assigned to either the no treatment group (76 patients) or the treatment group (59 patients). The treated group underwent treatment with cabergoline or bromocriptine before ovarian stimulation, until there was a decrease of plasma prolactin levels, and the therapy was continued also during the ICSI programme. Both groups received a gonadotropin-releasing hormone (GnRH) agonist and were subsequently stimulated with follicle-stimulating hormone (FSH) up to the day of human chorionic gonadotropin (hCG) administration. The untreated group needed a significantly lower number of FSH ampoules than the treated group to reach the day of hCG administration (38.1 ± 18.2 versus 43.9 ± 28.5; p < 0.05). No correlation was found between the two groups on the peak estradiol level achieved, the progesterone level at hCG administration and the numbers of oocytes retrieved. The number of oocytes with superior morphology (87.9% versus 80.4%; p < 0.05), the fertilization rate (70.8 ± 28.0 versus 60.8 ± 28.5; p < 0.03), and the mean number of embryos transferred (3.6 ± 1.6 versus 3.2 ± 1.5; p < 0.05) were significantly higher in the patients whose hyperprolactinemia was left untreated. In conclusion, we found that transient hyperprolactinemia is positively associated with ICSI outcome, in particularly with oocyte quality and fertilization rate.

Consecutive cycles in in vitro fertilization-embryo transfer

Background. The decline of female fertility with advancing age is well documented. The aim of this study was to compare the ovarian performance after repeated ovarian stimulation cycles in women of different ages. Methods. Four hundred patients who started at least three in vitro fertilization (IVF) cycles during the 5-year period between 1998 and 2002 were identified. The patients were divided into four groups: the 25–30 age group (n = 90), the 31–35 age group (n = 150), the 36–40 age group (n = 110) and the 41–45 age group (n = 50). Results. Comparing subsequent cycles versus the first treatment cycle we found a statistically significantly increased number of ampules of recombinant follicle stimulating hormone (rFSH) needed to reach follicles maturation (p < 0.001). The number of ampules of gonadotropin required was significantly higher (p < 0.001) in the groups of advanced age compared with the groups of young women. For women in the 36–40 group and in the 41–45 group we found the number of follicles, the number of oocytes and the proportion of grade A embryos, in every cycle, were significantly lower than in the groups of young women. We compared the characteristics of ovarian stimulation and response of a single age group in different consecutive cycles. We found significant differences (p < 0.05) only in the number of ampules required. Conclusions. Maternal age adversely affected ovarian performance. During repeated IVF cycles we also noted an age-independent decline of ovarian response.